CLINICALORTH]PAEDICS AND RELATEOFESEARCH Number390,pp. 31-41 @ 2001 LippinconWilliams & Wilkins, Inc.
ArthroscopicBankart Ilepair ExperienceWith an Absorbable,Transfu;ing lrnplant
Stephen Fealy, MD; Mark C. Drako,s,BA; t Answorth A. Allen, MD; and Russell F. Vlarren, MD I I
The useof arthroscopicmeans to addressshoul- scribedin 1938.:rTheessential lesion of shoul- der instability hasprovided a technicallyadvan- der instability, as describedby Bankart, is tageousway to approach Bankart lesionswhile thoughtby many to representthe most com- posing complex questions regarding the specific mon disorderunderlying possible causes for indicationsfor suchan intervention. A successful shoulderinstability.2'le'31 It represents a de- outcomewith arthroscopic Bankart repair is a tachmentof the labrumand its osseousinser- function of proper surgical indication and pa- glenoid. tient selection.Several authors have evaluated tion from the ant.eroinferior Reestab- the causesoffailure and reasonsfor successwith lishingthe structural integrity of the softtissue the Suretacdevice. The developmentof a bioab- to glenoidinterfrrce is theparamount objective sorbablerepair deviceat the authors'institution of the Bankaltv6rpair and has an essentialrole rvasprecipitated by a desire to addressand re- in surgeryfor sh,rulderstability. Although the pair Bankart lesions arthroscopically while traditional open Bankartrepair remains the avoiding the frequent complicationsassociatecl gold standardin treatmentoptions, continued rvith the metalstaple and the transglenoidsuture developmentof arthroscopictechniques and technique.The Suretacrepresents the first gen- the developmenr:of bioabsorbableimplants erationof bioabsorbable transfixingdevices. The has made arthrcscopy-basedprocedures for initial objectivesof the Suretac deviceryere to labral detachmelrtthe treatmentof choice at adequatelyand dynamicall_r'tensionsoft tissue to bone, lvhile providing a bioabsorption profile manycenters, inr:luding the authors' center. that mirrored the native healing response.The The adventof arthroscopicmeans to ad- Suretacdevice is an appropriatesurgical tool for dressshoulder instability has provided a tech- arthroscopicallyrepairing Bankart lesionsin a nically advantag,:ousway to approachthese carefullyselected patient population. lesions while posingcomplex questionsre- gardingthe speci[c indicationsfor suchan in- tervention.It is clearthat a successfuloutcome Treatmentof the Bankart lesion hasremained with arthroscopicBankart repair is a function a controversial topic since it was first de- of propersurgical indication. Patient selection is asimportant if notmore important than sur- gical technique.Research results previously From the Departmentof Sportsi\tedicine and Shoulder reportedindicate that the ideal candidatefor Service,Hospital for Speiiat Surgery,affiliated with CornellUnivirsiry Nlediial Center.-Ne* york, Ny. arthroscopicBanllart repair is onewho hasin- Reprintrequests to StephenFeal1.. N.lD, Hospital for Spe- stability attributableto a discreteBankart le- cial Surgery,535 East 70n Street.New yor.li,Ny l00i I . sionwithout conc,cmitant capsular laxity or in-
31 390 Clinical Number Orthopaedics September' 2O0- 32 Fealyet al and RelatedResearch a separateitrt repoft that of failureusing jury.a'29'30':z'3sThese authors open arlhroscopictechniques were treatedhad ret Bankart repair is more appropriatelyindicated consistentlyhigher than those produced using instabilitywitl for patients in whom there is a need for ante- opentechniques, although open rates ofrecur- labrum.Six pr rior and/or inferior capsularshift and patients rencehave been docrmented to be ashich as sion,which w who have generalizedcapsular laxity in addi- 377oin onestudy.r6 ROM and stre tion to the presenceof a discrete Bankart le- postoperativeh Developmentof Suretac sion. Open stabilizationprocedurcs generally tientsrePorted have failure rates less than l0%o.7Capsular Thedeveloprrent of a bioabsorbablerepair de- patientswho h laxity can be addressedeasily with open pro- viceat the authors' inr;titution was precipitated Elbow Sur-eeo cedures. Conversely, the prospect of treating by adesire to addressand repair Bankaft lesions pated in contr theseinjuries with decreasedmorbidity, pain, arthroscopicallyrvhilt: avoidingthe fiequent episodesof sut recovery tinre, and improved cosmesishas complicationsassociated with themetal staple The arthros' made arthroscopic Bankart repairs an attrac- and the transglenoidsuture technique. The noid suturetecl tive alternative.There have beetrseveral re- Suretac(Acufex N4i:rosurgical;Mansfield, provide minirr ports tlrat recognizethat opentechniques can MA) canbe placed afilrroscopically without an strengthto oPP produce a consistentlorv rate of recurrence, accessoryincision and avoids the technical dif- devicedesi,rlnt- but theseautlrors have observed a lossof nro- ficultyassociated rvith afthroscopic knot tying. limiting nrorbi, tion (particularly externalrotation).6'7'e'll A Initially,nretallic irntrrlants rvere chosen to hopefullywoul slower and lessconsistent ability to return to achievethe neccssaryl;oft tissueto bonefixa- tiveprofile to tl contact sports such as football also has been tion arlhroscopically.This interventionin- jured tissueret documented.a'7This observationcalls irrto cludedthe useof scre:rvs,staples, pins, and boneinterface. considerationthe role of arthroscopicover otherdevices. Horvever, conrplications arose irr while sinrultar openrepair of Bankartlesions for athleteswlro the form of loosening,migration, breakage, strengthin an i participatein contactspol'ts. The natureof cer- joint irnpingenrent.artic:ular cartilage danrage, limit thecontpl tain sports,rather than sur,gicaltechnique, is andincidence of painc:aused by the implant. manenceof the responsiblefor recurrenceof instabilityafter Reportsof recun'enceof instability after arthro- arthroscopicand open techniqueshave been scopicstapling rangcd between 3Vo and33Vo.l Scienceof the used. Poor positioningand subsequentntovement Device Severalauthols have compared open results andfatigue failure of the metallicstaple werc The Suretacltr with arthroscopicBankan repair results;the responsiblefor the high ratesof failureswith provide an adc cuffent authorswill discussthe outcornesof this device.It is this parlicularcomplication anteriorshould, thesestudies below. Arthroscopic treatment of thatprovided the inrpetur;to designbiodegrad- the shortcotttittl the Bankart lesionhas been addressed techni- able fixationdevices for orthopaedicproce- four primary in cally with repair using metallicstaples, trans- dureson the shoulder.l2.23 as outlinedby gle,noidsutures, bioabsorbable repair devices, Transglenoidsutures seemingly provided (l) adequate,t and arthroscopically-placedsutures and knot- an attraclivealternative to leavinga perma- strength;(2) a I Iesr;anchors. Arthloscopic repairof Bankarl le- nent devicein the sltoulder.However, the rorsthe healing sions,regardless of techniqueused, has been techniqueinitially requin:d an accessorypos- dynamicfixatio consistentlyassociated rvith rnore benefits than teriorincision and canied an associated risk of profilethat woL' opcn technique.Patients rvho undergo arthro- neurovascularinjury.lo.:0 In addition,the pro- tionin thejoint: scopic Bankart repair experienceless surgical cedurebears a risk of arti<:ularcartilage injury rial thatis meta nrorbidity,have better ran_se of rnotion(ROM), becauseof transscapularclrilling. Failure rates tionswithout ha and have quicker retum to full function than of transglenoidsuture repair have been re- carcinogenic,n tltose rvhoundergo open procedures. However, portedbetneen }Vo and 44Vo.7O'Neil2o re- erties. despite tlre variety of artluoscopicoptions to cently reportedhis expe.riencewith arthro- Polyglyconat Itddress Bankan lesions.several studies have scopicBankart repair using a transglenoid adheremost cl< rcporled hi-qherrates of failure postoperatively techniquein whichsuture l
(n CD x E40
C) 630 : t L.^ ol '" ]J at) 10 Fig 1. Side pull strengthof the bioabsorbableSuretac as a func- OO tion of time as comparedwith a metal staple.(Reproduced with permissionfrom KP Speer, RF ?345 Warre'n:Arthroscopic Shoulder Fig 3. PhotograPh lmplantation Time (weeks) Stabilization:A Role for Bio- tricribs along the sl degradableMaterials. Clin Orthop timatePullout strer 291:6,2-74,1993.) sionfrom Smith& | z[weeks altel the plocedureat the authors' in- lO-weekstudy.zl Ahhough the nretalstaple rectionalinstabilitr stitution.However. in a pilot study,the Sure- seemedto hinder repair libers from reestab- sularshift. The tc'cl tac rnediatedlixation was stronger than the lishingthe soft tissue osseous connection, the lar to using atrcltot' stapleand ren.lainedso fbr the duration of the Suletacprovided no such limitations.The be tensionedallPrc Suretacmay takeas Inanyas 6 rnonthsto be the Suretac,shtxrlt absorbedcompletely by the body. o'clock on a rigltt Sutureanchors, although technically chal- Suretacattd cotlve Ienging,recently have provided a meansof ad- rectlyat thearticul equatetissue fixation 'with minimal risk of in- the repair.Becaus jury to surroundingsoft tissuestructures.36 thehole is drilled s However,Shea et al27reported that the f,ailures anchor. of sutureand stapletr:chniques were signifi- cantlylower in thosevrith intact labrum-bone Rehabilitation complexes. Protectionof the is requiredt Surgicallndications: Suretac struct bility duringthe in Currently,the authors use the Suretac biodegrad- of 4 weeksrvith tl abledevice for patientswith a Bankartlesion, portant. During tl 'Type II superiorlabrunr anteriorand postedor cisesare allorved. . (SLAP)Iesion, or posteriorlabral separation (Fig doned,and irctil'e' Thequality 3).34 of thetissue must be adequate supervisionof a Pl to allowthe Suretac devir:e to hold.Capsular lax- is used to achievc FiE 2. The Suretacdevice has either a flat or ity,if present,should be treated with other surgi- spikedhead to grabsoft tissues. The headdiam- tion, whicll is begt cal eter is 6.5 mm for the flathead, and is 8 mm for options.Capsular ladty mustbe addressed Week 6, external the spikedSuretac ll. (Reprintedwith permission eitherwith a superiorsh,ift, thermal capsulorra- and progressedtc frornSmith & Nephew,Andover, MA.) phy,or capsularplication. Patients with multidi- Weightliftinginclr ClinicalOrthopaedics nd RelatedResearch Number390 September,2001 ArthroscopicBankart Repair 35
shoulder is allowed at Week 6, and bench pressin-q may be begun at approximately Weeks 8 to 10.lfhe authorsdo not allow over- head military pressesin patients treated with either arthroscopicor open techniques.Sports usually areresunred by 4 months after surgery. Using a more refined approach,the authors have found that .Bankartlesions repaired with . the Suretacdevice, will healas readily asType II SLAP lesions and posterior labral detach- ments that are re;rairedwith the Suretac.
Complications of the Suretac Device ) pullstrength of the )leSuretac as a func- Recently,Burkart et al-ireported on four cases as comparedwith a of synovitis caused by the Suretac device. ). (Reproducedwith Eachcase of sync,vitisu'as associated with re- fromKP Speer,RF currenceof shoulderinstability and failure of ihroscopicShoulder Fig 3. Photographof Suretacll device.Concen- the implant.Three of thesecases rvere SLAP : A Role lor Bio- tricribs along the shaftof Surelacimprove its ul- ;laterials.Clin Orthop timatepullout strength. (Reprinted with permis- repairsu'hereas the fourth was an arthroscopic 19s3.) sionfrom Smith & Nephew,Andover, MA.) Bankart repair.All four patientscomplatined of shoulderpain pre5lqpgratively.All four pa- tientshad an incre;rsein C-reactiveprotein and lr the metal staple , -. tionalinstability are treatecl rvith an open cap- an elevatederythrrrcyte sedimentation rate. In berufrom reestab- sularshift. The technicalaspect of thisare sinri- addition. subsequrlntarthroscopy revealed a onnection,the Iar to usincanchors in thtrtcapsular tissue may nrassivesynovitis with intraarticulareffusion l rtmitations.The be tensionc.dappropriately. Anchors, similar to in all four patients.In threeof the patients,the as 6 monthsto be the Surctac.slroulcl be place-clas low as 4 or 5 rvasbroken at the head-neckjr-rnction 'body. Suretac o'clock on a right shoulcler'.Placement of the of the device and loose fragn-rentshad fallen r technicallychal- Surctacand conventionalanchors nrust be di- into thejoint cavily. Bacterialctrltures in all decla meansof ad- rectlyat thcarticular rrrargin to avoidfailure of four prtientswere negative.Histologic evalu- ninimalrisk of in- thc rcpair. Bccauseof the heaclon a Suretac. ationrevealed a mrrssiveinfiltration oI phago- issuestructures.-36 lireholc isdrilled slightly more rncdially for an c1'ticcells includinil nrultinucleated giant cells edthat the failures tnchor. and histiocytes.Burkart anclcolleaguess ob- weresignifi- lues servedthat the Surotacnray be prone to early rtactlabrum-bone Rehabilitation failure particularlywith SLAP tears because Protectionof the repaireclcapsulolabral con- of its degradabilitl'profile. The current au- tac struct is requircdto avoid recurence of insta- thorsalso had severalciises of synovitis asso- bilitydurin-e the initial healing period. A period gleno- iuretacbiodegrad- ciatedwith placenre:ntof a Suretacfor of 4 weeksrvith the shoulder in a sling is im- (Fig case,the a Bankartlesion, humeral instability a). In each portant. Durin_qthis period. pendulum exer- 'rior and posterior patientpresented with a diffuseloss of motion ciscsare allorved. At 4 rveeks.the sling is aban- rralseparation(Fig and shoulderpain alter their index procedure. donecl,and activemotion is initiateduncler the arthroscopic nrustbe adequate S1'mptornsrvere relieved after supervisionof a physicaltherapist. Theraband rold.Capsularla,x- debridementand syrtovectomy. is useclto achieveexternal ancl internalrota- et al-jthree of l8 J with othersurgi- In the seriesof Burkhart tion. rvhichis begun4 u'eeksafter surgery. 81' patients(22Vo) with IiLAP lesionrepairs using rustbe addressed ',Veek 6, cxtelnal rotation art90" is initiatecl body reactions.Other ermalcapsulorra- the Suretachad foreign anrl progressedto a full ROM trs tolerated. studieshave shown si,unificantlylower com- entswith multidi- Weightlil'ting incluclingforu ard flexionof the plication rates with ,greaterstatistical power.
! i I, F C{inical 36 Fealyet al Orthopae6;, ano HetaledReseari;
Fig 5. Medial p Suretacor any i will repaira Bar nonanatomicsitr rectly responsibl, ure and recurr humeralinstabilit who underwent, anteriorshoulder metalanchors wr to the glenoid (medialto the f< tienthad an atrau Fig 4A-B- (A) sagittaloblique and (B) axialMRI scan of a patientrvho had synovitis developwithin 1 placement developfrom of thesuretac device 3 weeksafter arthroscopic repair of a l3ankartte6ion. rne gror"!r"no- procedure. humeraljoint effusionwith particulate debris can be seenon ihe sagit.:aland axialviews.
tarrceof portal Segmuller et alla reportedthree of 7l cases polynrerdebris :;urrounclcd bya hisriocytic in- ;:;f;llJnffil (4.2Vo)that showedan adversereaction to lhe filtrate. Such a linding could conrributero pr.eyiJusly.:r.:.r Suretacat a secondarthroscopy. Eclwarclss re- chronicinflalnrnation at thesite of repairmore Reschand collt ported sinrilarIinclings indicating that f,iveof than 6 nronlhs al'tcrthe initial proceclur.s..r2 of a low anteri( 100 patients(57c) rvho rveretreated with thc Warnerand a:;sociatcs.llnrade sevcr.al teclr_ scapularisto lt Suretacdevice had an adversereaction to the nical observatio:rs regardin-etheir use of thc glenoid.The au polyglyconate irrrplant. Three of the reported Suretacin a cacj'averlnodel. wlrich was ern- to be rvar.yof ;- five failures (60Vo)were in parientswho had beddedin a clearpolyrner. They crcareda dis- ntipirlallynredi SLAP repairs.It u,irspostulated that the early crete Bankart les;ionarthrosco'ically in eight glenoid,ivhich motion played a rcle in failure of the device.-s shouldersfiortr cadaversand then repairedthc Medial placenr, The current authorsrecornmend 4 weeks of lesionsusing the Suretac.The specinrel.lswere choring deyice immobilization witlr the shoulderin a sline dissectedto reve:al placenrentof the Suretac a nonanatoltric with daily pendulunrexerciscs wherr the Surel relative to the articular rnargin and scapular sponsibleforcl, tac is usedto repaira SLAP lesion.In a stuclv neck.They observed four consistenttechrrical gi.,.,olrunr".nli by Pagnaniand Warrenll l9 of 22 natients errorsin their repair of the Bankartlesion: ( I ) Other causef (86Vo) treated with the Suretac device for inadequateabrasion of the anteriorancl infe_ aclequatenunrl SLAP lesions reported results of satisfactory rior juxtaarticular scapular neck; (2) inade_ lique, chondral or better with rhe pr.oceclur.e.In addition. g6% quatesuperiol- and medial shift of the inferior huneral head.d presentedwith no or ntinintal loss of r.r.rotion glenohumeral ligament before placemenrof u,f.lu"t",rJii postoperatively.Ninety-one percent of the pa_ the lowest Suretitc;(3) rnedial placernentof ,io, tients reported a significant improvement iii the Suretacrelative -ef.nofru,rr" to the articularrnar.gin (Fi,g dure. ancl failLr: pain after the procedur.e.None of the patients 5); (4) and insufficientcapture and compres_ conservatiye presentedwith Suretac rel syrrovitis. sion ofcapsulartissue by the Suretacdevice. Wamer et al32selected a cohort of patients Warner et al32reported techrrical difficulty Suretac: Surgi specifically . with arthroscopicBankar-t repairs. in their ability to adequatelyabrade the an- As outlinedin tl Only two of l5 patientswith recunent insta- teroinferior scapurlarneck inferior to the 4 bility after Suretaccan be p artltroscopicBankart repairs with o'clock positio' on a right shourderthrough a parient in eitht the Suretacdevice had residual polyglyconate superoanterior afthroscopicportal. Tlre impor_ decubituspositi ClinicalOrthopaedics Number390 and RelatedResearch September,2001 ArthroscopicBankart Repair 37
Fig 5. Medialplacement of the Suretacor any anchoringdevice will repaira Bankartlesion at a nonanatomicsite and will be di- rectly responsiblefor clinicalfail- ure and recurrence of gleno- humeralinstability. In this patient, who underwentan open revision anteriorshoulder stabilization. the metalanchors were placed medial to the glenoid articularmargin (medialto the forceps).The pa- tienthad an atraumaticrecurrence within year iad synovitisdevelop from develop 1 of the index procedure. artlesion. The grossgleno- 'd axialviews. tanceof portal placementand the ability to shoulder arthroscopyri'ith the patient in the rc'achthe anteroinferiorntargin of the beachchair position.Proper placcrttent of the -clenoid tundedby a histiocyticin- ilr,'ou_than anteriorportal has bcenacldressed Suretacshould follo*' a step-wiseprogression: iine could contribute to pleviously.2r'2-r'33To avoid tlris difliculty, ( l) glenoid sit,rpreparation: Thc anteriorgle- 'he r '' siteof repairmore Reschand colleagues2srecornnrenclecl the usc noiclnrargin (irnnrediately acljacent to the gle- l. .itialprocedure.3l of a lorv anteriorportal that travcrsesthe sub- noiclarticular <:artilage) shoulcl bc debridedof irtcsll rnaclcscveral t,:ch- scapularisto reach the inferior lrrarginof thc any soft tissucs.ancl a blcetlinganterior margin :garclin-etheir use of thc glenoid.The authorscar.rtion the artlrroscopist is prcparcclto pronrotL-sofi tissuchcalin-g to the ' nrodel,which was em- to be wary of placenrentof the Surctaceven rnargin;(2)drill holeplitcerncttt: lt is intportant vrncr.They crcateda clis- minimallynredial to thearticular ntargin of the for the surgeonto bc arvarcthat there is a arthroscr.rpicallyin eight glcnoid,which only will yicld partialhealin_r. tenclencyfbr thc clrill to sliclcrrreclially alon-e ers anclthen repairedthe Nlcclialplacement of the Suretacor any an- the antcriorgle:noicl nc-ck: a 7-rttnt catrnttlais :tac.The specimensr.r,ere choringdevice will repaira Bankartlesion at plirceclinto the joint to allow passa-eeof the 'Iacernentof the Suretac il nonanatomicsite and will be directly re- Suretacinscrticn instruntc-ntation (Fig 6.4);the lar margin and scapular sponsiblefor clinical failLrreancl recLrmence of SLrretacdrill. u'ire, ancldlill hanclleare -euide tour consistenttechn ical glenohumeralinstability (Fig 5). placeda-sainst thc'labrunt and capsule and then rf the Bankartlesion: ( l) Other causesof complicationsinclude in- advancedint
E. F T r'a F Cl,nicalOrlhopaedics Number390^^^ 38 Fealy et al ard RelatedRbsear'5 september'2001
the two prinrary predicto stabilization procedures There is an inverse col andthe incidenceofrecu ure rate of all arthrosc, seernsto be attributablt rather than the bioabsor ratescan be minirnized with anteriorshouldel i to an acute.traurnatic er has a discreteBankaft velopedinferior glenohr Most recently,Cole : ated59 of 63 consecuttr went either arthroscol)i( pair of a Bankartlesiol the study \\'ere not ran tlaurnatic instability. I Fig 64-8. (A) The Suretacinsertion instrumentation is broughtinto the joint through a 7-mmcannuta. into two treatnrentgrot Caremust be taken to avoidmedial sliding of the guidepin duringinsertion. The ingle of the glenoid anrinationunder anestltr neck,as s;eenin this predisposes axialdrawing, the pin to slidemedially, away from the glenoidartic- tified at surgery.Paticnl ularmargin. (B) The Suretacdrill, guide wire, and drillhandle are placedagainst the labrum ano cap- hadonly anteriorinstab suleand then advancedinto the glenoid at the articularmargin. The drillis insertedto the depthof the actualSuretac implant.The drill should be removed,while keepingthe guide pin in the glenoid. sionduring examinatio (Reprintedwith permissionfrom Smith & Nephew,Andover, MA). the lesions were rep. with a Suretac.Patientr had anteriorand inferio arninationunder anestl with an open capsular was definedas recurrel tion, or presenceof app ical examination.Thcrr ference between groul of failure or any othe Twenty-four percento1 l87o of patientsin Glo tory outcome.Good tr ( observed in 84Voand patients,respectively.' a significant loss of f, pared with patients irr percentof patientsin I their previous level of curent instabilityu,er or event during contar 2 years postoperativel' Fig.7A-B- (A) The cannulatedSuretac bioabsorbable deviceis insertedover the guidiawire. The head The authors evaltr of the deviceshould oppose the capsulolabralcomplex to the articularmargin oT ther glenoid. (B) In- chronic,anterior instal traarticularvie_w of glenohumeraljoint after proper piacementof Suretacdevr-ces. (Repiinted with per- missionfrom Smith& Nephew,Andover, MA).' of 52 patientshad ins' ClinicalOrthopaedics Number390 and RelatedBesearch September,200.1 ArthroscopicBankart Repair 39
the two primary predictors of recurrenceafter sult of a traumaticevent. Fifty of 52 patients stabilization procedures of the shoulder.ls had a Bankart lesion.30 At a mean of 42 There is an inverse correlation between age monthspostoperatively,T9Vo of patientswere andthe incidence ofrecunence. The high fail- asymplomaticand in 2l%oof patients,the re- ure rate of all arthroscopic Bankart repairs pair wasconsidered a clinical failure.Seven of seemsto be attributableto patient selection the I I failures occurred atraumatically and in rather than the bioabsorbabledevice. Failure four palients,the repair was considereda clin- ratescan be minimized by selectirrgpatients ical failure as a result of a repeat traumatic with anteriorshoulder instabilityattributable event involving contactsports. The resultsof to an acute,traurnatic event where the patient the cunent study resultedin the development has a discreteBankart lesion and a well-de- of a more focusedindication for use of the ','llopedinferior glenohumeralligantent. Suretacat the authors'institution and a more Most recently,Cole and associatesTevalu- sensitiv,:appreciation of subtlecapsular laxitl' ated59 of 63 consecutivepatients who under- thatma)/ be seenin conjunctionwith a Bankart rventeither arthroscopic (Suretac)or open re- lesion. lJse of the Suretac rvas determined to pair of a Bankart lesion.Patients included in be an inappropriateindication for patients the study wcre not randonrized,and all had with a llankart lesion who had a significant traurnaticinstability. Patients were divided capsularinjury. The authors observedthat use rintthrough a7-mm cannula. into trvo treatntentgroups basedon their ex- of the Suretacto addressBankart lesionsand on. The angleof the glenoid arninationunder ernesthesia and disorder iden- capsularlaxity would result in an unaccept- away from the glenoid artic- I'liedat surgery.Patients in GroupI (N : 39) ably hi,ehrate of clinical f ailures.The Suretac againstthe labrumancl cap- rr.rdonly anteriorinstability with a Bankart ideallyu,ould be usedin patientswho s insertedto the depthof the le- suffered ,e -',ide pin in the glenoid. sionduring exantinationunder anesthesia and anteriorinstability as a result of a traumatic the lesions were repaircd arthroscopically event, arrd in those who had a robust and with a Suretac.Patients in Group II (N : 24) rnobile llankart lesion. Laurencin and col- hadanterior and inferiol instabilityduring ex- lea-9uesl:;reexanrined their arthroscopic arninationunder ancsthesia,ancl were treated Bankartresults w'ith the Suretacfbllorving op- with an open capsularshift. Clinical failure timized indicationsand found recurrentinsta- rvasdc-fincd as recurrentdislocation, subluxa- bility in l}c/cof 45 patients. tion,or presenceofapprehension during phys- Reschet al,2l usin-ean inferior transsub- icalexanrination. There was no significantdif'- scapularisportal to reach the anteroinferior f'crencebetween groups regardingincidence nrarginof the documenteda9Vo re- -slenoid, of failure or any other measuredparameter. currencerate in 98 patientsusing the Suretac. Trventy-fourpercent of patientsin Group I ancl Of the 318 proceduresthey did using the l87oof patientsin Group II had an unsatisfac- Suretac,no complicationswere reported.Simi- tory outconte.Good to excellentresults were larly,Karlsson and associatesla documented a observedin84Vo and 9l7o of Groups I and II l07c recurrencerate in 82 shouldersthat un- patients,respectively. Patients in Group II had derwent arthroscopicBankart repair rvith the a significantloss of forrvardelevation com- Suretacin patientswith rccurrent, posttrau- pared with patients in Group I. Seventy-five nratic ante:riorshoulder instability. The aver- percentof patientsin both groupsreturned to age Constantand Rowe score for these pa- theirprevious level of activity.AII casesof re- tients at an avera-geof 2 years postoperativel)' currentinstability were associatedwith a fall was 90 pointsand 93 points, respectively.No or eventduring contactsports rvithin the first patienthad evidence of a loss of motion in an_r' 2 yearspostoperatively. plane at fc'llowup.Segmuller et al2areported 'erthe guide wire. The head The atrthors evaluated 52 patients rvith their results in 7l shoulders in which the arginof the glenoid.(B) In- cltronic. anteriorinstability of theshoulder;49 Suretac was used. The cohort included pa- -.vices.(Reprinted with per- of'-5rpaticnrs had instabilitl,
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